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NORTH STAFFORDSHIRE INFIRMARY.
613
Gaining weight. Night-sweats entirely ceased. Appearing, red colour. The eruption is at places almost rupial. Chest: Good resonance Finally, there is one feature about the case that makes itas the mother said, "quite well." to nipple; behind, absolute dulness commenced at the tenth as a case of syphilitic herpes-very peculiar. Syphilitic rib, but there was deficient resonance above this, and the herpes is nearly always symmetrical on both sides of the note up to the middle of the scapula was not so clear as on body, but in the present instance the eruption appeared on the other side; breath-sounds nearly as loud as on the one side only, the right chest being perfectly intact. The opposite side. The right side now measured about a quarter case, therefore, must be regarded as extremely unusual." 2. Obscure Injury to Hip.-Mr. Hutchinson then showed of an inch less than the left, and expansion was still slightly an interesting case of obscure injury to the hip that was in deficient. the hospital under the care of Mr. McCarthy. A young lad, Wolverhampton. aged sixteen, a clerk, healthy, well-developed and intelligent, gave the following account of himself :-In August, 1878, while bathing in a swimming-bath, he attempted to jump over a horizontal bar into the water. He slipped, struck his right hip against the bar, fell upon a wooden OF platform beyond the bar, again striking the same hip, and HOSPITAL PRACTICE, then tumbled into the water. He was, however, able to . swim out of the bath, and to proceed home without assistBRITISH AND FOREIGN. ance, riding as far as possible in an omnibus, and accomthe remaining short distance on foot. He did not . Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum plishing a consult medical man, and indeed had never sought advice et dissectionum historias, turn aliorum, turn proprias collectas habere, et until he applied at the hospital (in March last). The morninter se comparare.—MoBaASNi De Sed. et Caus. Morb., lib.iv. Proceminm. ing after his accident he proceeded to his office as usual, walking with no other assistance than a stick, from Aldgate LONDON HOSPITAL. to the neighbourhood of Paternoster-row. This effort cost SURGICAL CASES AND CLINICAL REMARKS. him considerable pain about the hip, and " made him (Under the care of Mr. HUTCHINSON.) limp." He had, however, walked to and fro daily, without I FOR the following notes we are indebted to Mr. Frederick missing a single business day, and although the pain soon left him, he always walked a little lame, and with a certain Treves, F.R.C.S., surgical registrar. amount of discomfort. He stated that the right leg was not 1. Syphilitic Herpes. The patient was an unhealthy- shortened at first, but that, as month after month had gone looking man, a discharged soldier, aged thirty-five, withLby, the right leg had gradually become shorter, and his mode progression changed from an uncertain limp to the "up peculiar eruption running round the left side of his chest, atJ of and down" movement associated with a shortened extremity. once recognisable as a form of herpes zoster, or "shingles." the last month or so he had again used a stick on There was nothing in the position or general outline of the During account of the shortness of the limb. He had not felt able eruption that would distinguish it from ordinary herpes3 two run or indulge in violent exercise since the accident. On examination, the right leg was obviously shortened, zoster, but it would have been difficult to fail to notice at the first glance that its aspect was in some way different from and on actual measurement was found to be more than one what is usually seen in a simple case of this disease. On inch less in length than the sound limb. The lad walked with no pain, and no other discomfort than the inquiry it was found that the eruption had existed for no rapidly, shortness of the limb produced. The right limb was smaller less a period than nine months. The patient stated, more- than the left, and had apparently less muscular developover, that it was " much better " a few months before, butt ment ; it was perfectly straight, and was neither everted nor that it broke out again in (what he termed) a second attack, inverted. Passive movements excited no pain, and were only although the side had never been entirely free from eruption, limited in the direction of flexion. When the patient was even in the interval of amelioration. On examining the3 recumbent, the heel could be lifted about two feet from the eruption closely, it was seen that in some places there3 bed, but any elevation beyond that point was accompanied were distinct and prominent scabs ; the eruption here had1 by movement of the pelvis. The great trochanter was unevidently taken an ulcerative action, and approached in1 duly prominent, and was approximated to the iliac crest. some little degree to the characters of rupia. The skin1 The diagnosis was necessarily obscure, and rested mainly where the eruption had departed was of a dusky-red colour,, upon conjecture. It was suggested, as a possible explanation, and presented here and there a faintly depressed scar, show- an impacted fracture of the neck of the femur within the ing that there had been a loss of tissue. It was ascertained capsule, or an injury to the epiphysis of the head of the the man had had undoubted syphilis ; in fact, he had a largee bone, or a simple contusion of the bone. The first-mentioned periosteal node on the forehead at the moment. On thiss lesion would seem improbable in face of the fact that the account, but still more from certain peculiarities of thee boy was never laid up by the accident, and walked to his eruption itself, Mr. Hutchinson said he was of opinion thatt business next day without excessive difficulty. It is well this was a case of syphilitic herpes, and as such a very rareE) known that a simple contusion of the bone is stated to have affection. produced such wasting of the neck of the femur as to cause "Herpes," Mr. Hutchinson went on to say, "is, as is well1 considerable shortening of the limb ; and we can understand known, a skin disease of nerve origin. It is produced1 how an injury to the epiphysis, short of actual fracture or through some particular nerve influence, and, having regard1 separation, may produce a similar shortening by inducing therefore to its origin, we must consider the present case interstitial changes and absorption in the cervix femoris. not as an example of common herpes occurring in a syphilitic patient, and so possibly somewhat modified by that disorder, NORTH STAFFORDSHIRE INFIRMARY. but as a case where the poison of syphilis has caused such nerve changes as to bring about this eruption. The action CYSTIC TUMOUR OF THE RIGHT HALF OF THE LOWER of syphilis in this case is through the nervous system, and JAW ; REMOVAL ; RECOVERY; REMARKS. the eruption must be considered as an expression of some (Under the care of Mr. SPANTON.) disturbance of nerve. Thus we see syphilis as an syphilitic imitator of typical skin eruptions, and, as I have often stated, FOR the notes of the following interesting case we are it rarely, very rarely, imitates herpes. I consider this indebted to Mr. G. Russell, M.B., house-surgeon. eruption to be the syphilitic form of herpes on the following M. W-, aged forty-seven, married, was admitted on :-The man is syphilitic. The skin disease persistsgrounds it has persisted for nine months, with a recurrence of Jan. 13th, 1879. The family history was good, and she eruption during that time, whereas common herpes tends enjoyed perfect health until the appearance of the present to spontaneous cure, as do all skin affections that have their tumour. In December, 1876, she noticed a swelling the origin in the nervous system. It is most rare, too, for size of a marble over the angle of the right lower jaw; it common shingles to persist for so long a period as nine was immovable, hard, and painless, but gradually increasing months. It is true that it is sometimes very tardy in its disappearance, but, I think, never to such a degree as obtains in size. In September, 1877, she was an inmate of the in this instance. The scar left here and there by the clear- infirmary ; and at that time, on examining the right side of ing up of the eruption is depressed, distinct, and of a dusky- the face, a rounded swelling was observed, reaching up_______________
A Mirror
.
.
-
.
,
-
,
,
-
614 wards to the lower margin of the malar bone, downwards to the extent of half an inch below the margin of the lower maxillary bone, and extending backwards beyond the border of the jaw. In front it projected as far as the first molar tooth. The surface was smooth and fine; its centre somewhat elastic; while the whole was firmly attached to the bone. By the mouth it was felt to spring from the outer surface of the jaw, immediately beneath the alveolar border. The teeth were good, except the last molar, which was carious, but never gave her any pain; on being extracted, the fangs were found to be absorbed. The sensation on the right side of the chin was greatly impaired. The central part of the tumour was tapped with a fine trocar, and about six drachms of clear fluid drawn off, but this did not seem to diminish the size of the tumour. On readmission in January last, there was a swelling as . large as an orange extending forwards on to the face, while below and behind it reached beyond the natural border - of the bone, and in front as far as the first bicuspid tooth. The jaw could not be defined from the tumour. The most prominent part of its surface was fluctuant, and here the egg-shell crackle" could be made out. The mouth was firmly closed, and the patient had not eaten solid food for more than three months; her general health had consequently become much impaired. Severalears previously the patient had suffered from menorrhagia. As it was conjectured that this might throw some light on the nature of the tumour, a vaginal examination was made, and the uterus was found to be only slightly hypertrophied. The sound was passed easily, and the cavity was normal in length. On the night of admission (Jan. 13th) the tumour bled freely into the mouth, and on drawing aside the cheek a lesion was discovered running parallel to the alveolar border, from which dark venous blood was oozing; this became so free that it was found necessary to plug the space between the teeth and cheek with lint. On the 18th, under the influence of chloroform, the tumour An incision was made along the lower border was excised. of the jaw and posterior margin of the ramus, and the flap thus formed was dissected upwards. The tumour having been laid bare, the jaw was divided at the canine tooth, and all beyond it on the right side was removed. The tumour was then found to be one large cyst, whose walls were more or less bony, and whose consistence varied greatly at different points. The bone was excavated in its whole extent as far forwards as the bicuspid tooth, and upwards into the - coronoid process and condyle ; the former was perfectly hollow, while the head of the condyle was the only part of the latter which retained its normal texture. The inferior dental nerve was apparently uninjured. On the 20th the incision was healing by first intention in the greater part of its extent ; no oozing; and she partook of beef-tea freely. Pulse 90 ; temperature 102°. On the 26th the right half of face was oedematous, and the angle of the flap rather dark in colour. On February lst all the stitches were removed; the flaps had united. There was little discharge, but the face still remained oedematous, and the angle of the flap retained the ,dark colour. On the 10th she was allowed to get up and to take solid food. On introducing the finger into the mouth it was noticed that the bone was drawn towards the right side, and on examining the space a cicatricial band was found extending from the end of the bone towards the glenoid cavity, very tense, and preventing the parts from being replaced. On March lst the parts were completely healed. An - erysipelatous blush had just appeared over right side of face. Iron was ordered, and the was isolated. On the 5th the blush had greatly decreased, there being no pain, and the swelling was much less. On the 21st the patient was dismissed well. The erysipelas had subsided, and there was no discharge. The movement was increasing, and her general health was greatly
patient
improved. On April 26th she presented herself at the hospital. The movement of the jaw was very free, and the teeth could be applied to each other. She could masticate her food, and was enjoying perfect health. Remarks by iNIr. SPANTON.—IN this case we have an well developed example of simple cystic disease of the lower jaw, which appears to have been independent of dentigerous growth. I can find very few such cases recorded, though examples of the smaller cystic growths are
unusually not
uncommon.
Some difference of opinion seems to prevail as to the best mode of treating the affection, some surgeons puncturing only, some incising, others gouging away the walls of the tumour; while others again advocate entire removal through the adjacent healthy structures. A case somewhat similar is recorded as having been operated on in St. George’s Hospital in 1830. The tumour contained four ounces of fluid, and the patient died on the fourteenth day from erysipelas and diarrhoea. Another is related by Mason Warren, where the tumour extended over the whole ascending ramus of the right lower jaw from the angle to the coronoid process. An incision, with removal of a portion of the tumour, was followed in eighteen months by so-called cure, but an opening remained, from which glairy fluid was occasionally discharged. Subsequently a second tumour appeared anterior to the site of the first, was similarly treated, and with a like result. (Heath’s Injuries and Diseases of the Jaws, p. 390.) In the majority of the cases on record the tumours have consisted either of multilocular cysts or small single cystsespecially those which belong to the dentigerous class. Of the former cases, several instances are recorded in which, after repeated operations of a partial character, excision had to be resorted to. Sir J. Paget records one in which, after twice removing the cyst-wall, he had to remove a large portion of the jaw; Mr. Coote had a case in which death followed incision ; and others have occurred similarly from constitutional irritation. Dupuytren advocates strongly the emptying and compression of the cyst, and other surgeons since his day have been strongly in favour of some such method; but most of the instances related appear to have been of small size, such as most surgeons must have met with. In a patient, a youngwoman now under my care, who had a simple cystic tumour about the size of a walnut in the region of the second lower bicuspid tooth, I excised a portion of the bony wall, and, after gouging the pulpy cavity of the cyst, left it to granulate, and the cure has been perfectly
satisfactory. But in the case of M. W only one course was open, and that was to remove the entire half of the bone. Owing to the height of the tumour in the parotid and maxillary regions, it was rather difficult to disarticulate the maxilla entire, but it was accomplished with very little haemorrhage, and the result of the operation has been eminently satis-
factory. LIVERPOOL ROYAL INFIRMARY. CASE OF STONE IN THE
BLADDER ; LITHOTRITY SITTING ; REMARKS.
AT ONE
(Under the care of Mr. REGINALD HARRISON.) THE following case is noteworthy, chiefly because of the marked tendency to stone formation, the patient having previously been operated on twice by lithotomy and once by lithotrity. It further illustrates the practice recently advocated by Dr. Bigelow, of Boston, under the name of "litholapaxy." We are indebted to Mr. Renner for the notes of this case. J. A-, a ship-keeper, aged sixty-three, was admitted on April 22nd, 1879. Eight years before he suffered from symptoms of stone, for which he was cut, and a calculus was removed. Within a year he was again cut at another hospital, and two calculi were successfully removed. During the year previous to admission a stone was removed by lithotrity, and at the commencement of the present year the old symptoms again returned, when for the first time he came under Mr. Harrison’s notice. On admission he was suffering from frequent micturition, pain at the end of the penis, and occasional haematuria. The urine was purulent and deposited phosphates in abundance. On examining him under ether with a lithotrite, a round stone of about an inch in diameter was felt. On April 25th, the patient being placed under ether, Mr. Harrison broke up the stone, which was phosphatic, and evacuated the debris after the manner practised by Professor Bigelow. The symptoms were at once relieved, and the cystitis from which the patient had so long suffered gradually abated under treatment. Though the calculus was most completely broken up, there were no signs of haemorrhage, either during the time of operation or afterwards. He left the infirmary on May 15th,
’
Gaining weight. Night-sweats entirely ceased. Appearing, red colour. The eruption is at places almost rupial. Chest: Good resonance Finally, there is one feature about the case that makes itas the mother said, "quite well." to nipple; behind, absolute dulness commenced at the tenth as a case of syphilitic herpes-very peculiar. Syphilitic rib, but there was deficient resonance above this, and the herpes is nearly always symmetrical on both sides of the note up to the middle of the scapula was not so clear as on body, but in the present instance the eruption appeared on the other side; breath-sounds nearly as loud as on the one side only, the right chest being perfectly intact. The opposite side. The right side now measured about a quarter case, therefore, must be regarded as extremely unusual." 2. Obscure Injury to Hip.-Mr. Hutchinson then showed of an inch less than the left, and expansion was still slightly an interesting case of obscure injury to the hip that was in deficient. the hospital under the care of Mr. McCarthy. A young lad, Wolverhampton. aged sixteen, a clerk, healthy, well-developed and intelligent, gave the following account of himself :-In August, 1878, while bathing in a swimming-bath, he attempted to jump over a horizontal bar into the water. He slipped, struck his right hip against the bar, fell upon a wooden OF platform beyond the bar, again striking the same hip, and HOSPITAL PRACTICE, then tumbled into the water. He was, however, able to . swim out of the bath, and to proceed home without assistBRITISH AND FOREIGN. ance, riding as far as possible in an omnibus, and accomthe remaining short distance on foot. He did not . Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum plishing a consult medical man, and indeed had never sought advice et dissectionum historias, turn aliorum, turn proprias collectas habere, et until he applied at the hospital (in March last). The morninter se comparare.—MoBaASNi De Sed. et Caus. Morb., lib.iv. Proceminm. ing after his accident he proceeded to his office as usual, walking with no other assistance than a stick, from Aldgate LONDON HOSPITAL. to the neighbourhood of Paternoster-row. This effort cost SURGICAL CASES AND CLINICAL REMARKS. him considerable pain about the hip, and " made him (Under the care of Mr. HUTCHINSON.) limp." He had, however, walked to and fro daily, without I FOR the following notes we are indebted to Mr. Frederick missing a single business day, and although the pain soon left him, he always walked a little lame, and with a certain Treves, F.R.C.S., surgical registrar. amount of discomfort. He stated that the right leg was not 1. Syphilitic Herpes. The patient was an unhealthy- shortened at first, but that, as month after month had gone looking man, a discharged soldier, aged thirty-five, withLby, the right leg had gradually become shorter, and his mode progression changed from an uncertain limp to the "up peculiar eruption running round the left side of his chest, atJ of and down" movement associated with a shortened extremity. once recognisable as a form of herpes zoster, or "shingles." the last month or so he had again used a stick on There was nothing in the position or general outline of the During account of the shortness of the limb. He had not felt able eruption that would distinguish it from ordinary herpes3 two run or indulge in violent exercise since the accident. On examination, the right leg was obviously shortened, zoster, but it would have been difficult to fail to notice at the first glance that its aspect was in some way different from and on actual measurement was found to be more than one what is usually seen in a simple case of this disease. On inch less in length than the sound limb. The lad walked with no pain, and no other discomfort than the inquiry it was found that the eruption had existed for no rapidly, shortness of the limb produced. The right limb was smaller less a period than nine months. The patient stated, more- than the left, and had apparently less muscular developover, that it was " much better " a few months before, butt ment ; it was perfectly straight, and was neither everted nor that it broke out again in (what he termed) a second attack, inverted. Passive movements excited no pain, and were only although the side had never been entirely free from eruption, limited in the direction of flexion. When the patient was even in the interval of amelioration. On examining the3 recumbent, the heel could be lifted about two feet from the eruption closely, it was seen that in some places there3 bed, but any elevation beyond that point was accompanied were distinct and prominent scabs ; the eruption here had1 by movement of the pelvis. The great trochanter was unevidently taken an ulcerative action, and approached in1 duly prominent, and was approximated to the iliac crest. some little degree to the characters of rupia. The skin1 The diagnosis was necessarily obscure, and rested mainly where the eruption had departed was of a dusky-red colour,, upon conjecture. It was suggested, as a possible explanation, and presented here and there a faintly depressed scar, show- an impacted fracture of the neck of the femur within the ing that there had been a loss of tissue. It was ascertained capsule, or an injury to the epiphysis of the head of the the man had had undoubted syphilis ; in fact, he had a largee bone, or a simple contusion of the bone. The first-mentioned periosteal node on the forehead at the moment. On thiss lesion would seem improbable in face of the fact that the account, but still more from certain peculiarities of thee boy was never laid up by the accident, and walked to his eruption itself, Mr. Hutchinson said he was of opinion thatt business next day without excessive difficulty. It is well this was a case of syphilitic herpes, and as such a very rareE) known that a simple contusion of the bone is stated to have affection. produced such wasting of the neck of the femur as to cause "Herpes," Mr. Hutchinson went on to say, "is, as is well1 considerable shortening of the limb ; and we can understand known, a skin disease of nerve origin. It is produced1 how an injury to the epiphysis, short of actual fracture or through some particular nerve influence, and, having regard1 separation, may produce a similar shortening by inducing therefore to its origin, we must consider the present case interstitial changes and absorption in the cervix femoris. not as an example of common herpes occurring in a syphilitic patient, and so possibly somewhat modified by that disorder, NORTH STAFFORDSHIRE INFIRMARY. but as a case where the poison of syphilis has caused such nerve changes as to bring about this eruption. The action CYSTIC TUMOUR OF THE RIGHT HALF OF THE LOWER of syphilis in this case is through the nervous system, and JAW ; REMOVAL ; RECOVERY; REMARKS. the eruption must be considered as an expression of some (Under the care of Mr. SPANTON.) disturbance of nerve. Thus we see syphilis as an syphilitic imitator of typical skin eruptions, and, as I have often stated, FOR the notes of the following interesting case we are it rarely, very rarely, imitates herpes. I consider this indebted to Mr. G. Russell, M.B., house-surgeon. eruption to be the syphilitic form of herpes on the following M. W-, aged forty-seven, married, was admitted on :-The man is syphilitic. The skin disease persistsgrounds it has persisted for nine months, with a recurrence of Jan. 13th, 1879. The family history was good, and she eruption during that time, whereas common herpes tends enjoyed perfect health until the appearance of the present to spontaneous cure, as do all skin affections that have their tumour. In December, 1876, she noticed a swelling the origin in the nervous system. It is most rare, too, for size of a marble over the angle of the right lower jaw; it common shingles to persist for so long a period as nine was immovable, hard, and painless, but gradually increasing months. It is true that it is sometimes very tardy in its disappearance, but, I think, never to such a degree as obtains in size. In September, 1877, she was an inmate of the in this instance. The scar left here and there by the clear- infirmary ; and at that time, on examining the right side of ing up of the eruption is depressed, distinct, and of a dusky- the face, a rounded swelling was observed, reaching up_______________
A Mirror
.
.
-
.
,
-
,
,
-
614 wards to the lower margin of the malar bone, downwards to the extent of half an inch below the margin of the lower maxillary bone, and extending backwards beyond the border of the jaw. In front it projected as far as the first molar tooth. The surface was smooth and fine; its centre somewhat elastic; while the whole was firmly attached to the bone. By the mouth it was felt to spring from the outer surface of the jaw, immediately beneath the alveolar border. The teeth were good, except the last molar, which was carious, but never gave her any pain; on being extracted, the fangs were found to be absorbed. The sensation on the right side of the chin was greatly impaired. The central part of the tumour was tapped with a fine trocar, and about six drachms of clear fluid drawn off, but this did not seem to diminish the size of the tumour. On readmission in January last, there was a swelling as . large as an orange extending forwards on to the face, while below and behind it reached beyond the natural border - of the bone, and in front as far as the first bicuspid tooth. The jaw could not be defined from the tumour. The most prominent part of its surface was fluctuant, and here the egg-shell crackle" could be made out. The mouth was firmly closed, and the patient had not eaten solid food for more than three months; her general health had consequently become much impaired. Severalears previously the patient had suffered from menorrhagia. As it was conjectured that this might throw some light on the nature of the tumour, a vaginal examination was made, and the uterus was found to be only slightly hypertrophied. The sound was passed easily, and the cavity was normal in length. On the night of admission (Jan. 13th) the tumour bled freely into the mouth, and on drawing aside the cheek a lesion was discovered running parallel to the alveolar border, from which dark venous blood was oozing; this became so free that it was found necessary to plug the space between the teeth and cheek with lint. On the 18th, under the influence of chloroform, the tumour An incision was made along the lower border was excised. of the jaw and posterior margin of the ramus, and the flap thus formed was dissected upwards. The tumour having been laid bare, the jaw was divided at the canine tooth, and all beyond it on the right side was removed. The tumour was then found to be one large cyst, whose walls were more or less bony, and whose consistence varied greatly at different points. The bone was excavated in its whole extent as far forwards as the bicuspid tooth, and upwards into the - coronoid process and condyle ; the former was perfectly hollow, while the head of the condyle was the only part of the latter which retained its normal texture. The inferior dental nerve was apparently uninjured. On the 20th the incision was healing by first intention in the greater part of its extent ; no oozing; and she partook of beef-tea freely. Pulse 90 ; temperature 102°. On the 26th the right half of face was oedematous, and the angle of the flap rather dark in colour. On February lst all the stitches were removed; the flaps had united. There was little discharge, but the face still remained oedematous, and the angle of the flap retained the ,dark colour. On the 10th she was allowed to get up and to take solid food. On introducing the finger into the mouth it was noticed that the bone was drawn towards the right side, and on examining the space a cicatricial band was found extending from the end of the bone towards the glenoid cavity, very tense, and preventing the parts from being replaced. On March lst the parts were completely healed. An - erysipelatous blush had just appeared over right side of face. Iron was ordered, and the was isolated. On the 5th the blush had greatly decreased, there being no pain, and the swelling was much less. On the 21st the patient was dismissed well. The erysipelas had subsided, and there was no discharge. The movement was increasing, and her general health was greatly
patient
improved. On April 26th she presented herself at the hospital. The movement of the jaw was very free, and the teeth could be applied to each other. She could masticate her food, and was enjoying perfect health. Remarks by iNIr. SPANTON.—IN this case we have an well developed example of simple cystic disease of the lower jaw, which appears to have been independent of dentigerous growth. I can find very few such cases recorded, though examples of the smaller cystic growths are
unusually not
uncommon.
Some difference of opinion seems to prevail as to the best mode of treating the affection, some surgeons puncturing only, some incising, others gouging away the walls of the tumour; while others again advocate entire removal through the adjacent healthy structures. A case somewhat similar is recorded as having been operated on in St. George’s Hospital in 1830. The tumour contained four ounces of fluid, and the patient died on the fourteenth day from erysipelas and diarrhoea. Another is related by Mason Warren, where the tumour extended over the whole ascending ramus of the right lower jaw from the angle to the coronoid process. An incision, with removal of a portion of the tumour, was followed in eighteen months by so-called cure, but an opening remained, from which glairy fluid was occasionally discharged. Subsequently a second tumour appeared anterior to the site of the first, was similarly treated, and with a like result. (Heath’s Injuries and Diseases of the Jaws, p. 390.) In the majority of the cases on record the tumours have consisted either of multilocular cysts or small single cystsespecially those which belong to the dentigerous class. Of the former cases, several instances are recorded in which, after repeated operations of a partial character, excision had to be resorted to. Sir J. Paget records one in which, after twice removing the cyst-wall, he had to remove a large portion of the jaw; Mr. Coote had a case in which death followed incision ; and others have occurred similarly from constitutional irritation. Dupuytren advocates strongly the emptying and compression of the cyst, and other surgeons since his day have been strongly in favour of some such method; but most of the instances related appear to have been of small size, such as most surgeons must have met with. In a patient, a youngwoman now under my care, who had a simple cystic tumour about the size of a walnut in the region of the second lower bicuspid tooth, I excised a portion of the bony wall, and, after gouging the pulpy cavity of the cyst, left it to granulate, and the cure has been perfectly
satisfactory. But in the case of M. W only one course was open, and that was to remove the entire half of the bone. Owing to the height of the tumour in the parotid and maxillary regions, it was rather difficult to disarticulate the maxilla entire, but it was accomplished with very little haemorrhage, and the result of the operation has been eminently satis-
factory. LIVERPOOL ROYAL INFIRMARY. CASE OF STONE IN THE
BLADDER ; LITHOTRITY SITTING ; REMARKS.
AT ONE
(Under the care of Mr. REGINALD HARRISON.) THE following case is noteworthy, chiefly because of the marked tendency to stone formation, the patient having previously been operated on twice by lithotomy and once by lithotrity. It further illustrates the practice recently advocated by Dr. Bigelow, of Boston, under the name of "litholapaxy." We are indebted to Mr. Renner for the notes of this case. J. A-, a ship-keeper, aged sixty-three, was admitted on April 22nd, 1879. Eight years before he suffered from symptoms of stone, for which he was cut, and a calculus was removed. Within a year he was again cut at another hospital, and two calculi were successfully removed. During the year previous to admission a stone was removed by lithotrity, and at the commencement of the present year the old symptoms again returned, when for the first time he came under Mr. Harrison’s notice. On admission he was suffering from frequent micturition, pain at the end of the penis, and occasional haematuria. The urine was purulent and deposited phosphates in abundance. On examining him under ether with a lithotrite, a round stone of about an inch in diameter was felt. On April 25th, the patient being placed under ether, Mr. Harrison broke up the stone, which was phosphatic, and evacuated the debris after the manner practised by Professor Bigelow. The symptoms were at once relieved, and the cystitis from which the patient had so long suffered gradually abated under treatment. Though the calculus was most completely broken up, there were no signs of haemorrhage, either during the time of operation or afterwards. He left the infirmary on May 15th,
’